benefits, services, and copayments...dental services: emergency, preventive and routine you may use...

KidzPartners is pleased to provide you with the following information on benefits, services and copays you have with KidzPartners, as well as what is not covered. Please call our Member Relations department anytime if you have any questions, at 1-888-888-1211 (TTY 711).

5. BENEFITS, SERVICES AND COPAYMENTS

Copays Children are enrolled into “free,” “low-cost” or “full-cost” CHIP based on family income and related information that you provide in your application. In the low-cost and full-cost programs, some of your KidzPartners benefits require a copayment or “copay” that you pay directly to the provider each time you get services, as described below.

All members enrolled in KidzPartners: There are no CHIP copays for preventive care services, including well-child visits and visits for immunizations, for members in any premium category.

Members enrolled in “free” KidzPartners: There are no CHIP copays for any services for any members enrolled in the free program.

Members enrolled in “low-cost” KidzPartners pay the following CHIP copays: • $5 for visits to your children’s primary care

physician, except for well-child visits • $5 for visits to specialists • $25 for visits to the emergency room. This copay

is waived if your child is admitted. • $9 for brand name formulary drugs and

$6 for generics

The annual maximum you will pay for copays is five percent of your family income.

Members enrolled in “full-cost” KidzPartners pay the following CHIP copays: • $15 for visits to your children’s primary care

physician, except for well-child visits • $15 for visits to any physician other than your

PCP (specialist and behavioral health providers) • $50 for visits to the emergency room. This copay

is waived if your child is admitted. • $18 for brand name formulary drugs and

$10 for generics

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KidzPartners Benefits The following chart provides an overview of your coverage with KidzPartners. Please also see “Non-Covered Services” at the end of this section and Special Needs Services (Section 7).

Note: Except in an emergency, ALL services from non-participating providers require prior authorization from Health Partners Plans.

KidzPartners Benefit How to Obtain This Benefit

Primary Care Services: Covered for both sick visits and well-child/preventive care.

You select your own primary care provider (PCP) from our network of participating providers and make your own appointments.*

Acupuncture: Up to 20 visits per year are covered for members 16 and older.

Select a provider from our acupuncture network. There is no copay.

Ambulance/Transportation Services: All modes of emergency transportation are covered. Non-emergent transport is not covered. Transportation between facilities/providers is covered if it’s medically necessary, and not solely for convenience.

For emergencies, call 911.

Autism Services: Medically necessary services for the assessment/treatment of autism spectrum disorders are covered.

There is no annual dollar limit or maximum on services for the assessment/treatment of autism spectrum disorders.

Contact your PCP or treating specialist.

Prior authorization requirements are listed in this benefit grid. Some of the services used to assess and treat autism spectrum disorders may require prior authorization.

Services for the assessment/treatment of autism spectrum disorders will be subjected to copayments and any other general exclusions or limitations listed in this handbook.

Chiropractic Services: Up to 20 visits per year Contact your PCP or treating specialist. are covered.

Consultations: By specialists, including second opinion No prior authorization. consultations to determine the medical necessity of elective surgery, or when a member’s family desires another opinion about medical treatment.

Dental Services: Emergency, preventive and routine You may use any dentist listed in our provider directory.* dental cares are covered. Also see “Dental Care” Certain services require prior authorization. See Section 6 for in this section. information on prior authorization.

Diabetes Self-Monitoring Supplies: Formulary blood Members must use a participating pharmacy. Prescription glucose meters, test strips, lancet devices and lancets, required. Prior authorization may be required. Copays may and glucose control solutions for checking test strip/ apply. See also “Prescription Drugs” in this table. monitor accuracy are covered.

Disease Management Programs: Programs are available Contact your PCP, or call our Disease Management to help you manage diabetes, pediatric obesity, and department at 1-866-500-4571. asthma. Smoking cessation counseling is also available to members enrolled in Disease Management programs. Covered in full.

Drug and Alcohol Abuse – Inpatient Hospital No copays apply. No referral needed. Members as young Treatment: Covered. as 14 can self-refer.

Contact Magellan Behavioral Health of PA at 1-800-424-3701. See “Drug and Alcohol Treatment and Mental Health Services” in Section 7 for more information about Magellan.

Drug and Alcohol Abuse – Non-Hospital Residential No copays apply. No referral needed. Members as young Treatment: Covered. as 14 can self-refer.

Contact Magellan Behavioral Health of PA at 1-800-424-3701.

Drug and Alcohol Abuse – Outpatient Treatment: Covered. No copays apply. No referral needed. Members as young as 14 can self-refer.


*To find a KidzPartners participating provider, see the KidzPartners Provider Directory or our online directory at HealthPartnersPlans.com, or call Member Relations at 1-888-888-1211 (TTY 711).

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https://www.HealthPartnersPlans.com


Durable Medical Equipment (DME): Rental costs are Provider prescription is required. Prior authorization is covered for wheelchairs, or other equipment for home required for DME over $500 and all rentals. or school for therapeutic use, up to the total cost of purchase, or the purchase of durable medical equipment will be covered.

Family Planning Services: Birth control pills, injectables, Contact your PCP, gynecologist or family planning provider. patches, and insertion and implantation of contraceptives, including devices, are covered.

Fitness Program: Annual membership covered in See “Fitness Program Membership” in this section. participating facilities; participation requirements apply.

Gynecological Services: Covered Contact your PCP, gynecologist or any family planning provider. No prior authorization or referrals are required.

Habilitative Services – Outpatient Therapies: Covered up Prior authorization is required after the first 8 visits to 30 visits per therapy per year; for physical, speech, of PT/OT combined. and occupational therapy.

Unlimited visits for chemotherapy, radiation therapy, Prior authorization required after the 8th visit of respiratory therapy and dialysis. speech therapy.

Hearing: Emergency, preventive and routine hearing care, Contact your PCP. No copay is required for services provided including audiologist visits when referred by the PCP, by the PCP. Specialist copay applies for audiologist visits. is covered.

Hearing Aids - One hearing aid per ear is covered Contact your PCP. Prior authorization is required. every two years.

Home Health Care: This includes nursing services; Contact your PCP or your treating specialist. physical, speech and occupational therapies; medical Prior authorization is required. and surgical supplies; oxygen and its administration; home medical equipment.

Home Infusion: Covered when medically necessary. Contact your PCP or your treating specialist. Prior authorization is required.

Hospice Care – Inpatient and Outpatient: Covered Contact your primary care provider. Prior authorization when medically necessary. and Certification of Terminal Illness are required.

Hospital Services – Inpatient: Acute hospital care, Prior authorization is required for all physical health inpatient rehabilitation and behavioral health are non-emergency admissions. Notification and authorization covered when medically necessary. are required for emergent admissions.

Hospital Services – Outpatient: Medically necessary Prior authorization is required for all outpatient surgery, outpatient hospital services are covered. and certain other services as noted elsewhere in this

benefits chart.


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Injections and Medications: Provided in the physician No copays apply. office, a hospital, or freestanding ambulatory service Prior authorization may be required. center, including immunizations and anesthesia service when performed in connection with covered services

Laboratory and Radiology Services: Covered. PCP prescription is required. Prior authorization is required for advanced radiology such as CT, MRI, PET scans, stress echocardiography, cardiac nuclear medicine imaging, and radiation therapy.

Mastectomy: Medical and surgical benefits with respect Contact your PCP or treating specialist. to mastectomy are covered when medically necessary.

Mental Health Services – Inpatient: Covered when No copays apply. No referral needed. Members as young medically necessary. as 14 can self-refer.


Mental Health Services – Outpatient: Covered. No copays apply. No referral needed. Members as young as 14 can self-refer.


Mental Health Services – Partial Hospitalization: No copays apply. No referral is needed. Members as Covered when medically necessary. young as 14 can self-refer.


Newborn Care: Covered for a newborn child of member To ensure no lapse in access to health care for the newborn for 31 days following birth. after the first 31 days, the member must contact Member

Relations immediately after child is born to begin the process of getting the newborn his or her own health care coverage.

Obstetrical Services: Mothers and infants can remain No prior authorization or referrals are required for maternity in the hospital for 48 hours after a normal delivery hospital admissions. or 96 hours after a cesarean delivery. Treatment for

Contact your PCP or your treating specialist. Prior complications is also covered. authorization is not required for the first for two maternity

Well-mother/well-baby home visits: Members are health care visits provided at their home following release covered for two maternity health care visits provided from inpatient maternity site. at their home following release from inpatient maternity

Contact your PCP, or call our Baby Partners program for site. Visits include parent education, assistance and pregnant members at 1-866-500-4571 or 215-967-4690. training in breast and bottle feeding, infant screening,

clinical tests, and the performance of any necessary mother and baby assessments.

Our Baby Partners program is available to help you manage your health care while you are pregnant. Smoking cessation counseling is available. Covered in full.

Oral Surgery: Covered Specialist copay applies. Prior authorization is required when services are provided in a facility.

Organ Transplants: Covered for the member as recipient, Prior authorization is required. Donor transplant services when medically necessary and not experimental/ covered only when the member is the transplant recipient, investigative. Formulary immunosuppresants are and when Health Partners Plans can verify that these also covered. services are not covered by the donor’s insurance.


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Orthodontia: Medically necessary orthodontic treatment is Medically necessary orthodontic services require prior approval. covered by CHIP. Orthodontia is not covered for cosmetic reasons. See “Orthodontics” in the Dental Care section.

Prescription Drugs: Formulary drugs are covered. Includes Members must use a participating pharmacy.* Copays may self-administered injectable medications and diabetes apply. Prior authorization required for certain medications. self-monitoring supplies.

Preventive Care/Well-Child Care: All items or services, including Contact your PCP. No copays apply. preventative medications, recommended by the United States Preventive Services Task Force (USPSTF) A and B, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention and the Health Resources and Services Administration (HRSA) are covered.

Private Duty Nursing – Inpatient: Covered when medically Contact your PCP or your treating specialist. necessary. No limit.

Prior authorization required.

Prosthetics and Orthotics: Covers the purchase of prosthetic Contact your PCP or your treating specialist. devices and supplies, including fittings and adjustments;

Prior authorization is required for prosthetics and replacements covered only when deemed medically necessary orthotics over $500. and appropriate.

Reconstructive Surgery: Covered when required to restore Contact your PCP or treating specialist. function following an accidental injury as a result of a birth defect, infection, or malignant disease in order to achieve reasonable physical or bodily function; in connection with congenital disease or anomaly through the age of 18; or in connection with the treatment of malignant tumors or other destructive pathology which causes functional impairment; or breast reconstruction following a mastectomy.

ScriptSave: Special discount card for prescription drug/discount ScriptSave card will be mailed to you. that can be used by entire family.

Skilled Nursing Facility Services: Covered when Contact your PCP. Prior authorization is required. medically necessary.

Smoking Cessation Services: Covered. Contact KidzPartners Member Relations at 1-888-888-1211.

Special Needs Unit (SNU) Services: The Special Needs Unit Contact your primary care provider or SNU at 1-866-500-4571. provides case management for members who may require extra assistance getting needed care for their illnesses, disabilities, or other special needs. Covered in full.

Specialist Physician Services: Covered. Contact your PCP.

Vision Care: Preventive and routine vision care are covered. Contact any KidzPartners participating vision care provider This includes the cost of exams, corrective lenses, frames, and for preventive/routine vision care services. medically necessary contacts, not to exceed one routine eye exams and refraction including dilation a year and one pairs of eyeglasses (lenses and frames) or contact lenses a year. Discounts available for special lens treatments. See “Vision Care” in this section.

Weight Watchers®: Membership is covered when program Members pay a $2 weekly meeting fee. Contact KidzPartners requirements are met. See “Weight Watchers Benefit” in Members Relations at 1-888-888-1211. this section for more information.

Well Women Preventative Care: Covered according to the No copays apply. Prior authorization is not required. Women’s Preventative Services provisions of the Patient Protection and Affordable Care Act.


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Acupuncture Acupuncture is an alternative to drugs and other treatments for headaches, back or neck pain and other health issues. All members 16 and older are covered for 20 visits annually and when visiting our specially credentialed acupuncture providers. When you go to the acupuncturist, he or she will make a treatment plan just for you. The provider then uses needles or other ways to stimulate specific points in the body to relieve pain. To find a licensed acupuncturist in our network, check our online provider directory at HealthPartnersPlans.com or call KidzPartners Member Relations at 1-888-888-1211 (TTY 711).

Asthma Checkups If your children have or you suspect they may have asthma, make sure they are on the right medication to help prevent asthma episodes. Checkups are covered as a primary care service. Call Member Relations at 1-888-888-1211 (TTY 711) for information on KidzPartners’ Asthma Management program.

Clinical Trials If your children are eligible to participate in an approved clinical trial (according to trial protocol), with respect to treatment of cancer or other life-threatening disease or conditions, and either the referring provider is a participating provider who has concluded that participation in the trial would be appropriate, or you furnish medical and scientific information establishing that his or her participation in the trial would be appropriate, benefits shall be payable for routine patient costs for items and services furnished in connection with the trial. Health Partners Plans must be notified in advance of the member’s participation in the qualifying clinical trial.

Routine patient costs associated with qualifying clinical trials: Benefits are provided for routine patient costs associated with participation in a qualifying Clinical Trial. To ensure coverage and appropriate claims processing, KidzPartners must be notified in advance of the member’s participation in a Qualifying Clinical Trial.

Benefits are payable if the Qualifying Clinical Trial is conducted by a participating professional provider, and conducted in a Participating provider facility. If there is no comparable Qualifying Clinical Trial being performed by a participating professional provider, and in a participating provider facility, then KidzPartners will consider the services by a non-participating provider, participating in the clinical trial, as covered if the clinical trial is deemed a Qualifying Clinical Trial by KidzPartners.

Qualifying clinical trials: A phase I, II, III, or IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is described in any of the following:

1. Federally funded trials: the study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:

a. The National Institutes of Health (NIH);

b.The Centers for Disease Control and Prevention (CDC);

c. The Agency for Healthcare Research and Quality (AHRQ);

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d.The Centers for Medicare and Medicaid Services (CMS);

e. Cooperative group or center of any of the entities described in 1-4 above or the Department of Defense (DOD) or the Department of Veterans Affairs (VA);

f. Any of the following, if the conditions For departments are met:

• The Department of Veterans Affairs (VA); • The Department of Defense (DOD) and the

Department of Energy (DOE), if for a study or investigation conducted by a Department, or that the study or investigation has been reviewed and approved through a system of peer review that the Secretary determines to be (A) comparable to the system of peer review of studies and investigations used by the National Institutes of Health, and (B) assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.

2. The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or

3. The study or investigation is a drug trial that is exempt from having such an investigational new drug application. The citation for reference is 42 U.S.C. §300gg-8. The statute requires the issuer

to provide coverage for routine patient care costs for qualified individuals participating in approved clinical trials and issuer “may not deny the individual participation in the clinical trial.”

In the absence of meeting the criteria listed above, the clinical trial must be approved by KidzPartners as a Qualifying Clinical Trial.

Routine patient costs associated with qualifying clinical trials include all items and services consistent with the coverage provided under this plan that is typically covered for a qualified individual who is not enrolled in a clinical trial.

Covered Preventative Medications Select medications such as contraceptives, iron supplements, sodium fluoride, folic acid supplements, vitamins, aspirin, smoking deterrents, vitamin D supplements, tamoxifen, and raloxifene are considered preventive medications and covered at no cost to you when filled at a participating pharmacy with a valid prescription. If you have questions about whether a preventive medication is covered, call Member Services at 1-888-8880-1211 (TTY 711).

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Dental Care Your children are covered for a broad range of routine dental services and preventive care. You can go to any of the general dentists or dental specialists listed in the Provider Directory. Just select a dentist from this list and call the office to make an appointment. Your children do not need a referral for a dental visit.

The plan covers Diagnostic and Treatment Services, Preventative Services, Palliative Treatment of Dental Pain, Minor Restorative Services, Endodontic Services, Periodontal Services, Prosthodontic Services, and Major Restorative Services. Covered dental services include:

• Anesthesia • Checkups (two per year) • Periodontal services • Routine Prophylaxis (Cleanings, scaling and polishing

of teeth), two per year, with the exception of pregnant women who shall be eligible for one additional prophylaxis during pregnancy.

• Root canals • Crowns • Sealants • Dentures • Dental surgical procedures • Dental emergencies • X-rays • Extractions (tooth removal) • Fillings • Occlusal Guard by report • Orthodontics (see next section)

For more information on your children’s dental benefits, please call KidzPartners Member Relations anytime at 1-888-888-1211 (TTY 711).

Orthodontics Medically Necessary Orthodontic treatment must be considered medically necessary and the only method to prevent irreversible damage and restore your children’s teeth and supporting oral structures to health. All services require prior approval, a written plan of care, and must be performed by a participating provider. Braces for cosmetic reasons are not covered.

Diabetes Checkups If your children have or you suspect they may have diabetes, it is important they have a blood test called HbA1c, which will check the average amount of sugar in their blood over the past 2-3 months. It is also important to have a cholesterol test called an LDL. Diabetes checkups (including these tests) are covered as a primary care service. Diabetic children should also get dilated eye exams, which are covered under KidzPartners’ vision benefit. Call KidzPartners Member Relations at 1-888-888-1211 (TTY 711) for information on KidzPartners’ Diabetes Management program.

Family Planning Services KidzPartners members can get family planning services through their PCP or any doctor or clinic of their choice including those not in KidzPartners’ network. These services may include pregnancy testing, testing and treatment for sexually transmitted diseases, basic birth control supplies, and counseling.

Fitness Program Membership Exercise helps children stay healthy and feel good about themselves. That’s why KidzPartners offers special memberships at participating YMCAs and other fitness centers. To qualify for a year-long membership at a participating center, members under 18 must complete six visits within the first three months. Members 18 and older must complete 12 visits during the introductory period, and pay a $2 copay for each visit.

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After completing these visits, no copay is required for the rest of their one-year fitness membership period.

You must sign a fitness enrollment form during your children’s first visit to the fitness center. For more information, please call KidzPartners Member Relations at 1-888-888-1211 (TTY 711).

Formulary KidzPartners has a formulary. A formulary is a list of medicines that a health plan approves for use. Your children’s doctor uses our formulary when choosing medicines for them. The formulary contains two kinds of drugs: brand name drugs and generic drugs. Generic drugs contain the same active ingredients as brand name drugs. Since they work the same way as the brand name drugs, you can feel sure that these drugs are high quality and safe for you to take. The formulary also includes certain over-the-counter (non-prescription) drugs that doctors frequently recommend for children.

If the medicine your children’s doctor wants to use is not part of the formulary, he or she can ask that Health Partners Plans approve the drug for you through the medical exception process. Your doctor will need to send a Letter of Medical Necessity (LOMN) to Health Partners Plans’ Pharmacy department. This LOMN must explain why your children need the medicine and why formulary alternatives cannot be used, when applicable. Health Partners Plans will review your doctor’s request and make a decision within 24 hours of receiving the request.

Habilitative Services • Health care services that help a person keep,

learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of outpatient settings. Covered services are limited to 30 visits per calendar year for Physical Therapy;

30 visits per calendar year for Occupational Therapy; and 30 visits per calendar year for Speech Therapy, for a combined visit limit of 90 days per calendar year. Visit limits under this benefit are combined with visit limits described under Outpatient Rehabilitation Therapy.

• Covered services also include inpatient therapy up to 45 visits per calendar year for treatment of CVA (Cerebral Vascular Accidents), head injury, spinal cord injury or as required as a result of post-operative brain surgery.

• Chiropractic Care – limit 20 visits per year • Home Health Care: Care provided to a KidzPartners

member who is homebound by a home health care provider in the KidzPartners member’s home, if within the service area. This benefit is offered with no copayments and no limitations.

Hearing Care Services Hearing aids and devices and the fitting and adjustment of such devices are covered when determined to be medically necessary.

Benefits Limits: One routine hearing examination and one audiometric examination per 12 months. One hearing aid or device per ear every 24 months. Batteries for hearing aids and devices are not covered. No monetary limits apply.

Home Health Care If your child becomes sick or hurt, medical care may be available in your home. Your child’s PCP will talk to you and, if appropriate, will then contact Health Partners Plans to request prior authorization for these services.

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Hospitalization If your children need to be admitted to a hospital, your KidzPartners PCP will arrange for them to go to a KidzPartners participating hospital. Their PCP will continue to follow your children’s care even if they need other doctors. Hospital admissions, except for emergencies, need prior authorization (pre-approved) by Health Partners Plans.

Mastectomy and Breast Reconstruction Benefits are provided for a mastectomy performed on an inpatient or outpatient basis, and for the following:

• Surgery to reestablish symmetry or alleviate functional impairment, including, but not limited to augmentation, mammoplasty, reduction mammoplasty and mastopexy, surgery and reconstruction of the other breast to produce a symmetrical appearance.

• Coverage for initial and subsequent prosthetic devices to replace the removed breast, or portions thereof, due to a mastectomy; and

• Physical complications of all stages of mastectomy, including lymphedemas.

• Coverage is also provided for one Home Health Care visit, as determined by the member’s physician, received within 48 hours after discharge.

Maternity Care Prenatal care is the care you need when you find out you are pregnant. It is important for you and the health of your unborn child. When you find out that you are pregnant, call your obstetrician/gynecologist (OB/GYN) right away. If you do not have an OB/GYN, just call the Member Relations department or your PCP to pick one. It is important to your health and your baby’s health to visit your OB/GYN the first three months of your pregnancy.

If you are newly enrolled in KidzPartners, schedule an appointment to see your OB/GYN immediately. During these visits, your OB/GYN will do important things to keep you and your baby healthy, like asking you questions about your medical history, giving you a physical exam and vitamins, and giving you tests to make sure you do not have any conditions like diabetes or high blood pressure.

KidzPartners covers all the OB/GYN visits you need before your baby is born, without copays. Regular checkups after the birth are also covered. It is important that you have checkups after you deliver your baby. You should see your doctor within three to six weeks after you have the baby or if you have any problems. If your OB/GYN ever leaves KidzPartners, or if you are a new enrollee and are seeing an OB/GYN who is not in KidzPartners’ network, you have the right to request to continue seeing this doctor for your remaining prenatal care and follow-up care after the birth.

When you are pregnant, the covered care includes: • Vitamins • Hospital stays • Hospital delivery and nursery • Treatment for any maternity-related complications • Smoking cessation • Tests recommended or conducted by your OB/GYN

Through our Baby Partners program, KidzPartners provides all pregnant moms with important information about prenatal dental care. Moms who take good care of their teeth have healthier babies! Dental insurance covers routine prophylaxis (including clean, scaling and polishing of teeth) once every 6 months, with the exception of a member under the care of a medical professional for pregnancy, who shall be eligible for one additional prohpylaxis during pregnancy.

In addition, KidzPartners offers two home visits to every new mom and her newborn. Visits are usually scheduled within the first two weeks and the second two weeks following hospital discharge. Staying with KidzPartners throughout your pregnancy will help assure that you and your baby receive all necessary care.

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KidzPartners offers its pregnant members additional assistance through our Baby Partners program. This includes talking to a case manager who can assist with questions you may have about your pregnancy and a welcome packet with important information on how to stay healthy while you are pregnant. For more information on our Baby Partners program, contact Member Relations at 1-888-888-1211 or the Baby Partners line at 1-866-500-4571 (TTY 711).

CHIP coverage will be extended to babies born to CHIP members for 31 days. It is important to apply for Medical Assistance or CHIP right after the birth of the child to provide continued coverage for the baby. Only one application needs to be completed to apply for both programs.

Maternity Services A female member may select a participating provider for maternity and gynecological services without a referral or prior authorization. Hospital and physician care services relating to antepartum, intrapartum, and postpartum care, including complications resulting from the member’s pregnancy or delivery, are covered.

Under federal law, health plans and health insurance issuers generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.

Coverage is also provided for at least one (1) home health care visit following an inpatient release for maternity care when the CHIP member is released prior to 48 hours for a normal delivery and 96 hours for a cesarean delivery in consultation with the mother and provider, or in the case of a newborn, in consultation with the mother or the newborn’s authorized representative.

Home health care visits include, but are not limited to: parent education, assistance and training in breast and bottle feeding, infant screening and clinical tests, and the performance of any necessary maternal and neonatal physical assessments. A licensed health care provider whose scope of practice includes postpartum care must make such home health care visits. At the mother’s sole discretion, the home health care visit may occur at the facility of the provider. Home health care visits following an inpatient stay for maternity services are not subject to copayments, deductibles, or coinsurance, if otherwise applicable to this coverage.

Member Education Classes KidzPartners offers educational programs in many communities. Classes are available to help your children quit smoking, help you have a healthy baby, and help you become a better parent. KidzPartners also offers education to help members deal with special health problems, like asthma. Watch for information about these and other education sessions in your member newsletter. You can also call the Member Relations department for details about current classes 1-888-888-1211 (TTY 711).

Outpatient Services Outpatient services, such as X-rays and laboratory tests, are also covered. Your KidzPartners PCP will arrange for these services at a KidzPartners participating hospital or a participating outpatient center.

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Pediatric Preventive Care Pediatric Preventive Care includes the following, with no cost-sharing or copays:

• Physical examination, routine history, routine diagnostic tests.

• Oral Health Risk Assessment, fluoride varnish for children ages 5 months to 5 years old (U.S. Preventative Task Force Recommendation).

• Well baby care, which generally includes a medical history, height and weight measurement, physical examination and counseling.

• Blood lead screening and lead testing. This blood test detects elevated lead levels in the blood.

• Hemoglobin/Hematocrit. This blood test measures the size, shape, number and content of red blood cells.

Prescription Drug Benefits If your children needs medicine, their PCP or specialist will write a prescription. Simply take it to one of the nearly 900 area pharmacies (drug stores) that fill KidzPartners prescriptions. Your prescription will be filled if your children are active KidzPartners members and the prescribed drug is on our formulary. Depending on your CHIP category, you may be charged a copayment for your prescription.

Sometimes you may be charged a copayment for a prescription by mistake. If you think you should not have to pay a copayment, please contact Member Relations or the pharmacy for assistance. If the pharmacist tries to charge you the wrong amount for a prescription, please ask him or her to contact Health Partners Plans.

If you need help finding a pharmacy, or would like a complete list of participating pharmacies, call our Member Relations department anytime at 1-888-888-1211 (TTY 711). You can also check the KidzPartners Provider Directory, or visit us online at HealthPartnersPlans.com to find participating pharmacies.

If your children’s doctor makes his or her request for Health Partners Plans approval after you have already taken the prescription to the pharmacy, Health Partners Plans, while reviewing the request, will in most cases cover a 5-day supply of the medicine if your children have not already been taking the medicine and a 15-day supply if they have already been taking the medication.

We will let you and the doctor know whether we will approve the medicine for you. If we deny your children’s doctor’s request, you have the right to file a complaint or grievance. Since new drugs and treatments are put into use all the time, Health Partners Plans will make changes to the KidzPartners formulary as needed.

Select over-the-counter (OTC) products may be covered if mandated by the Patient Protection and Affordable Care Act (PPACA). If the member has a prescription for the over-the-counter medication, the medication is listed in the formulary, and the member has been diagnosed with certain medical conditions, the medication may be covered. If you have questions about whether an over-the-counter medication is covered, call Member Relations at 1-888-888-1211 (TTY 711).

When a prescription drug is available as a generic, KidzPartners will only provide benefits for that prescription drug at the generic drug level. If the prescribing physician indicates that the brand name drug is medically necessary and should be dispensed, the brand name drug is covered at the generic cost-share amount by KidzPartners.

When clinically appropriate, drugs are requested by the member, but are not covered by the health plan, the member should call customer service at the telephone number on the back of the member’s identification card to obtain information for the process required to obtain the prescription drugs.

If you would like a copy of the KidzPartners formulary, please call our Member Relations department at 1-888-888-1211 (TTY 711) or visit our website at HealthPartnersPlans.com.

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Primary and Preventive Health Services KidzPartners periodically reviews the Primary and Preventive Care Covered Services based on recommendations from organizations such as The American Academy of Pediatrics, the American College of Physicians, the U.S. Preventive Services Task Force (USPSTF) (all items or services with a rate of A or B in the current recommendations), the American Cancer Society and the Health Resources and Services Administration (HRSA). Examples of covered “USPSTF A” recommendations are folic acid supplementation, chlamydial infection screening for non-pregnant women, and tobacco use counseling and interventions. Examples of covered “USPSTF B” recommendations are dental cavities prevention for preschool children, healthy diet counseling, oral fluoride supplementation/rinses and vitamins, BRCA risk assessment and genetic counseling and testing, prescribed Vitamin D, prescribed iron supplementation, mineral supplements, chlamydial infection screening for pregnant women, and sexually transmitted infections counseling. Examples of covered HRSA required benefits include all Food and Drug Administration approved contraceptive methods, sterilization procedures, breastfeeding equipment, and patient education and counseling for all women with reproductive capacity. All services required by HRSA are covered. Accordingly, The Preventive Health Services are provided at no cost to the member.

Reconstructive Surgery Reconstructive Surgery will only be covered when required to restore function following accidental injury, result of a birth defect, infection, or malignant disease in order to achieve reasonable physical or bodily function in connection with congenital disease or anomaly through the age of 18; or in connection with the treatment of malignant tumors or other destructive pathology, which causes functional impairment; or breast reconstruction following a mastectomy.

Vision Care Visits for routine eye exams and glasses or medically necessary contact lenses are covered. A participating vision provider must be used. Your child does not need a referral from a PCP to see a vision provider. There are no copayments for routine eye examinations. If any vision service is provided under the medical benefit for a diagnosis of cataracts, keratoconus or aphakia, then a copayment may apply.

Frames and lenses: One set of eyeglass lenses that may be plastic or glass, single vision, bifocal, trifocal, lenticular lens powers and/or oversized lenses, fashion and gradient tinting, oversized glass-gray #3 prescription sunglass lenses, polycarbonate prescription lenses with scratch resistance coating and low vision items.

Frequency of eye exam: One routine examination and refraction every 12 months. The examination includes dilation, if professionally indicated. There is no Cost to member in network services. There is no coverage for out-of-network services.

Frequency of lens and frame replacement: One pair of eyeglasses every 12 months when medically necessary for vision correction.

Lenses: For in network, one pair is covered in full every calendar year. There is no coverage for out-of-network.*

There are no copayments for covered standard eyeglass lenses (Single Vision, Conventional [Lined] Bifocal, Conventional [Lined] Trifocal, Lenticular).

Note: Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, oversized and glass-gray #3 prescription sunglass lenses.

Polycarbonate lenses are covered in full for children, monocular patients and patients with prescriptions > +/- 6.00 diopters.

All lenses include scratch-resistant coating.

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There may be copayments for optional lens types and treatments:

Ultraviolet Protective Coating No Copay Polycarbonate Lenses (if not child, monocular or prescription >+/-6.00 diopters) $30 Blended Segment Lenses $20 Intermediate Vision Lenses $30 Standard Progressives $50 Premium Progressives (Varilux®, etc.) $90 Photochromic Glass Lenses $20 Plastic Photosensitive Lenses (Transitions®) $65 Polarized Lenses $75 Standard Anti-Reflective (AR) Coating $35 Premium AR Coating $48 Ultra AR Coating $60 Hi-Index Lenses $55

Frames: Collection Frame – no cost to member. Non-Collection Frame – expenses in excess of $130 allowance payable by member. Additionally, a 20 percent discount applies to any amount over $130. There is no coverage for out-of-network services.

Replacement of lost, stolen or broken frames and lenses (one original and one replacement per calendar year) when deemed medically necessary.

Contact lenses: One prescription every year – in lieu of eyeglasses or when medically necessary for vision correction.

Expenses in excess of a $130 allowance (may be applied toward the cost of evaluation, materials, fitting and follow-up care). Additionally, a 15 percent discount applies to any amount over $130.

Additional discounts may be available from participating providers.

Note: In some instances, participating providers charge separately for the evaluation, fitting, or follow-up care relating to contact lenses. Should this occur and the value of the contact lenses received is less than the allowance, you may submit a claim for the remaining balance (the combined reimbursement will not exceed the total allowance).

Out-of-network exclusion only applies if child is in his or her coverage area at time of eyeglass/contact replacement. If your child is unexpectedly out of the area (e.g.,vacation), and they need replacement contacts or eyeglasses, their expenses can be sent to the plan for reimbursement.

Expenses in excess of $600 for medically necessary contact lenses, with pre-approval, include these conditions:

Aphakia, pseudophakia or keratoconus, if the patient has had cataract surgery or implant, or corneal transplant surgery, or if visual activity is not correctable to 20/40 in the worse eye by use of spectacle lenses in a frame but can be improved to 20/40 in the worse eye by use of contact lenses.

KidzPartners covers routine vision exams. (Treatment of other eye problems may be covered as a medical benefit. Your children’s PCP can refer you to an eye specialist if necessary.)

Your children’s vision benefit includes two annual vision exams, and two pairs of eyeglasses or two pairs of prescription contact lenses per year. Additional replacement eyeglasses can be authorized if medically necessary.

When your children need a vision exam, just check your KidzPartners Provider Directory or call Member Relations at 1-888-888-1211 (TTY 711) for help finding a convenient vision care provider. When you call to make an appointment, be sure to tell the office your children are members of KidzPartners. Remember to bring your children’s membership ID cards with you to the appointment.

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Your children’s vision benefit also includes one comprehensive low vision evaluation every 5 years, with a maximum charge of $300; maximum low vision aid allowance of $600 with a lifetime maximum of $1,200 for items such as high-power spectacles, magnifiers and telescopes; and follow-up care – four visits in any five year period, with a maximum charge of $100 per visit.

Providers will obtain the necessary pre-authorization for these services. The benefit is not covered if performed by an out of network provider.

Weight Watchers® Benefit When children are overweight, those extra pounds can contribute to heart disease, high blood pressure and diabetes. And they can also cause problems with their confidence and self-image. That’s why KidzPartners wants to help them with weight loss through Weight Watchers of Philadelphia, Inc.

You pay only a $2 weekly meeting fee when your children enroll in the KidzPartners Enhanced Benefit Weight Watchers program and meet program requirements.

To qualify, they must (1) attend 10 consecutive weekly meetings, and (2) lose at least one pound a month. If your children continue to meet the program requirements, their benefit will continue for successive 10-week periods.

Due to Weight Watchers requirements, participation is limited to members age 13 and older. Weight Watchers requires a doctor’s note with a goal weight for children ages 13 – 17. For additional information about the program, call KidzPartners Member Relations anytime at 1-888-888-1211 (TTY 711).

Well-Child Visits You can make appointments with your children’s PCP for well-child visits designed to keep them healthy. The primary and preventive care services children should have during these visits include:

Regular checkups: From the time they are born, it is very important for your children to visit their PCP regularly for well-child checkups, including routine blood pressure screening. Babies need checkups at 1, 2, 4, 6, 9, 12, 15 and 18 months; children need annual checkups starting at age two. In addition to providing a comprehensive physical exam, your children’s PCP will arrange for any needed lab or other diagnostic testing. These visits help assure that your children stay healthy.

Shots/immunizations: Children should have many important shots before age two in order for the shots to have the most effect. Children should also continue to have shots, including boosters and flu shots, as necessary. Whenever your children see their PCP, be sure to check that their shots are up to date.

Immunizations and Screenings Coverage will be provided for pediatric Immunizations (except those required for employment or travel), including the immunizing agents, which conform to the standards of the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control, the U.S. Department of Health and Human Services. Pediatric and adult Immunization ACIP schedules may be found by accessing the following link: http://www.cdc.gov/vaccines/recs/ schedules/index.htm.

Influenza vaccines can be administered by a participating pharmacy for members starting at the age of nine years old, with parental consent, according to PA Act 8 of 2015.

Health education: Your children’s PCP will provide information and advice on important health issues, including prevention/cessation of all types of tobacco use, and healthy eating habits.

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http://www.cdc.gov/vaccines/schedules/index.html

http://www.cdc.gov/vaccines/schedules/index.html

Developmental screening: Checkups by your children’s PCP will include screenings to check that your children’s physical and learning development are on track.

Allergy diagnosis and treatment: For children exhibiting symptoms of possible allergies, preventive care includes diagnosis and treatment.

BMI: Ask your children’s doctor about their Body Mass Index (BMI). This may help you determine whether your children are at risk for obesity.

Young women’s health screens: As your daughters become young women, routine women’s health care should include checkups, Pap tests and breast exams. Check with your children’s PCP for more information.

Well Woman Preventive Care There is no cost sharing for preventative services under the services of Family Planning, Women’s health, and Contraceptives.

Well Woman Preventive Care includes services and supplies as described under the Women’s Preventive Services provision of the Patient Protection and Affordable Care Act. Covered services and supplies include, but are not limited to, the following:

Routine gynecological exam, Pap smear: Female members are covered for one (1) routine gynecological exam each benefit period. This includes a pelvic exam and clinical breast exam; and routine Pap smears in accordance with the recommendations of the American College of Obstetricians and Gynecologists. Female members have direct access to care by an obstetrician or gynecologist. This means there is no primary care physician referral needed.

Mammograms: Coverage will be provided for screening and diagnostic mammograms. Benefits for mammography are payable only if performed by a qualified mammography service provider who is properly certified by the appropriate state or federal agency in accordance with the Mammography Quality sStandards Act of 1992. Copayments, if any, do not apply to this benefit.

Breastfeeding: Comprehensive support and counseling from trained Providers; access to breastfeeding supplies, including coverage for rental of hospital-grade breastfeeding pumps under durable medical equipment (DME) with medical necessity review; and coverage for lactation support and counseling provided during postpartum hospitalization, mother’s option visits, and obstetrician or pediatrician visits for pregnant and nursing women at no cost share to the member.

Contraception: Food and Drug Administration-approved contraceptive methods, including contraceptive devices, injectable contraceptives, IUDs and implants; voluntary sterilization procedures, and patient education and counseling, not including abortifacient drugs, at no cost share to the member. Contraception drugs and devices are covered under the Prescription Drug benefit issued with the plan.

Osteoporosis screening (bone mineral density testing or BMDT): Coverage is provided for BMDT using a U.S. Food and Drug Administration approved method. This test determines the amount of mineral in a specific area of the bone. It is used to measure bone strength, which is the aggregate of bone density and bone quality. Bone quality refers to architecture, turnover and mineralization of bone. The BMDT must be prescribed by a professional provider legally authorized to prescribe such items under law.

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Reimbursement Except for copays, you should never have to pay out of pocket for a covered service. If you do choose to pay for a service (for example, if you go to a new pharmacy and forget your KidzPartners ID card and pay for a prescription out of pocket), you can request that we repay you. We can send you a special form to help you give us all the information we need to make a decision about your request. If you have questions or would like to request a form, please call KidzPartners Member Relations at 1-888-888-1211 (TTY 711). If your request for reimbursement is approved, we will notify you and send you a reimbursement check.

Non-Covered Services There are some health care services that are not covered by KidzPartners. Except for certain “extra” benefits offered by KidzPartners, KidzPartners will not cover health care services that are not included in the Pennsylvania Children’s Health Insurance Program.

Some of the services and situations not covered by KidzPartners include the following: • Services that are not medically necessary • Administrative costs, such as charges for completing

health forms or for missed appointments • Alternative medicine, such as massage therapy

and yoga • Any service that is not provided or ordered by your

KidzPartners PCP or specialist, except for emergency, mental health and substance abuse, and family planning services

• Consumable supplies • Cosmetic surgery such as face lifts, tummy tucks,

nose jobs or any surgery intended solely to improve appearance; only surgery considered to be reconstructive or restorative with prior authorization

• Food supplements • Home modifications • Infertility services

• Items for comfort or convenience, such as air conditioners and exercise equipment

• Mental retardation services • Non-formulary drugs, unless pre-approved by

Health Partners Plans • Non-prescription eyeglasses or contact lenses • Organ donation to non-members • Paternity testing • Physical exams performed primarily to meet

third-party requirements, such as for school, camp, sports participation, or a driver’s license

• Podiatry • Respite care • Services offered or covered by other programs,

such as Medicare, Worker’s Compensation, or Veterans Administration

• Services provided by non-participating providers, excluding emergencies

• Services provided outside the United States and its territories, with limited exceptions in Canada, Mexico and U.S. territorial waters

• Services requiring prior authorization if this authorization is not obtained

• Temporomandibular joint (TMJ) syndrome treatment • Transportation provided for member convenience • Weight reduction surgery

No health plan covers everything. This managed care plan may not cover all your health care expenses. If you are not sure if a particular service is covered by KidzPartners, it is important to check with your PCP or KidzPartners Member Relations at 1-888-888-1211 (TTY 711).

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benefits, services, and copayments...dental services: emergency, preventive and routine you may use...

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